General and weight-loss surgery: 57% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2026 · Urgent care · age 41–50 Breast proc · Injury Poison Oth The physician reviewer found that a patient has requested reimbursement for medical services. The capsulectomy and implant removal did not meet the criteria for an emergency or urgent operation. The procedure was scheduled and performed at a surgery center…

   The physician reviewer found that a patient has requested reimbursement for medical services. The capsulectomy and implant removal did not meet the criteria for an emergency or urgent operation. The procedure was scheduled and performed at a surgery center, not in a hospital following an emergency room admission. It occurred 16 days after the patient’s most recent surgical evaluation. The record does not document emergent or urgent symptoms such as acute, medication‑refractory pain or extracapsular rupture with silicone leakage outside the capsule or through the skin. Perioperative discussions also centered on aesthetic considerations, including implant replacement, fat grafting, and mastopexy. Accordingly, the patient did not receive emergency medical services or urgent care services. Final Result: The reviewer determined that the services at issue were not emergency medical services or urgent care services as defined by California law. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR26-46660

2. Overturned 2026 · Medical necessity · age 51–64 CNS extracranial/autonomic · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for the Intracept procedure. Medical literature supports basivertebral nerve ablation as a treatment option for chronic axial low back pain. The patient has persistent…

   The physician reviewer found that a patient has requested authorization and coverage for the Intracept procedure. Medical literature supports basivertebral nerve ablation as a treatment option for chronic axial low back pain. The patient has persistent symptoms despite multiple conservative therapies, including medication management and physical therapy. Given this clinical history and the evidence supporting the intervention, the Intracept procedure is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in anesthesiology with subspecialty certification pain medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46974

3. Upheld 2026 · Medical necessity · age 31–40 CNS extracranial/autonomic · Disease Eye Adnexa The physician reviewer found that a patient has requested authorization and coverage for a stellate ganglion nerve block procedure performed with anesthesia. Medical literature does not support stellate ganglion block as an evidence‑based treatment for…

   The physician reviewer found that a patient has requested authorization and coverage for a stellate ganglion nerve block procedure performed with anesthesia. Medical literature does not support stellate ganglion block as an evidence‑based treatment for post‑LASIK pain, neuropathic corneal pain, or photophobia, although it is used for other conditions such as complex regional pain syndrome. Based on the available evidence and the patient’s clinical presentation, the requested procedure is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46970

4. Upheld 2026 · Medical necessity · age 0–10 Male genital proc · Kidney and urinary The physician reviewer found that a patient’s parent has requested authorization and coverage for circumcision. While newborn circumcision is supported by medical literature as an elective procedure with potential health benefits, circumcision later in…

   The physician reviewer found that a patient’s parent has requested authorization and coverage for circumcision. While newborn circumcision is supported by medical literature as an elective procedure with potential health benefits, circumcision later in infancy requires medical indication. In this case, the patient has normal anatomy and no documented condition requiring circumcision. Therefore, circumcision is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in urology with subspecialty certification in pediatric urology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46965

5. Overturned 2026 · Medical necessity · age 31–40 Hemic/Lymph nodes/channels · Kidney and urinary The physician reviewer found that a patient has requested authorization and coverage for any or all of the hysterectomy procedure components. First‑line treatment for abnormal uterine bleeding is medical management, and the medical records document failure of…

   The physician reviewer found that a patient has requested authorization and coverage for any or all of the hysterectomy procedure components. First‑line treatment for abnormal uterine bleeding is medical management, and the medical records document failure of such therapy, supporting the need for hysterectomy. Therefore, laparoscopic total hysterectomy is medically necessary for the treatment of this patient.Lymph node dissection and related oncologic procedures are not performed for benign indications, and the submitted records do not document findings concerning for malignancy. Given the absence of a documented concern for gynecologic cancer, the additional oncologic procedure components are not medically indicated.Given these findings, the hysterectomy procedure component (laparoscopic total hysterectomy) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in maternal and fetal medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46960

6. Upheld 2026 · Medical necessity · age 51–64 CNS extracranial/autonomic · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for bilateral lumbar radiofrequency ablation for lumbar facet‑mediated pain. Current clinical standards note that diagnostic accuracy is improved when two medial branch…

   The physician reviewer found that a patient has requested authorization and coverage for bilateral lumbar radiofrequency ablation for lumbar facet‑mediated pain. Current clinical standards note that diagnostic accuracy is improved when two medial branch blocks are performed before proceeding with radiofrequency ablation. In this case, although the patient experienced significant pain relief from a medial branch block, the documentation reflects only a single diagnostic block. As a result, the criteria supporting radiofrequency ablation have not been met. Therefore, bilateral lumbar radiofrequency ablation is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46958

7. Overturned 2026 · Medical necessity · age 31–40 CNS extracranial/autonomic · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for the Intracept procedure. Medical literature describes basivertebral nerve ablation as a treatment option for vertebrogenic low back pain, and evidence supports its use in…

   The physician reviewer found that a patient has requested authorization and coverage for the Intracept procedure. Medical literature describes basivertebral nerve ablation as a treatment option for vertebrogenic low back pain, and evidence supports its use in appropriately selected patients with chronic symptoms and Modic type 1 or 2 changes. Clinical studies demonstrate meaningful and durable improvements in pain and function with this therapy. In this case, the patient has severe, function‑limiting axial low back pain, failure of extensive conservative measures, and Modic changes on imaging. Given these findings, the requested Intracept procedure is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46945

8. Overturned 2026 · Medical necessity · age 51–64 MSK surg pelvis/hip proc · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed. The American Society of Pain…

   The physician reviewer found that a patient has requested authorization and coverage for injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed. The American Society of Pain and Neuroscience guideline recommends image‑guided intra‑articular corticosteroid injections for sacroiliac joint pain that persists despite conservative measures. Clinical studies show that sacroiliac injections can reduce pain scores and may provide relief for over three months. In this case, the patient presents with chronic low back pain involving adjacent regions and has undergone multiple prior interventional and conservative treatments. The physical examination includes findings consistent with sacroiliac joint involvement, and imaging shows additional musculoskeletal changes that do not exclude sacroiliac pathology. Based on the medical literature, sacroiliac injections are effective for reducing pain in appropriately selected patients. Given these findings, the requested injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46930

9. Overturned 2026 · Medical necessity · age 51–64 MSK surgical spine proc · Injury Poison Oth The physician reviewer found that a patient has requested authorization and coverage for percutaneous vertebral augmentation for the back. Sacral insufficiency fractures occur when normal physiologic loads are applied to weakened sacral bone, often related to…

   The physician reviewer found that a patient has requested authorization and coverage for percutaneous vertebral augmentation for the back. Sacral insufficiency fractures occur when normal physiologic loads are applied to weakened sacral bone, often related to osteoporosis or other conditions that reduce bone strength. Initial treatment is typically conservative, but minimally invasive procedures such as percutaneous sacroplasty can provide rapid pain relief and improved mobility when symptoms are severe or nonoperative management fails. In this case, the patient has a history of sacral insufficiency fractures, chronic back pain, osteoporosis, cervical cancer, and prior radiation and chemotherapy treatment. Given these findings, the requested percutaneous vertebral augmentation for the back is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46928

10. Upheld 2026 · Medical necessity · age 65+ Parathy/Thymus/Adrenal/Pancrs · Hormones and metabolism The physician reviewer found that a patient has requested authorization and coverage for radiofrequency ablation. The U.S. Food and Drug Administration (FDA) approves radiofrequency ablation as a treatment option for benign thyroid nodules, and medical…

    The physician reviewer found that a patient has requested authorization and coverage for radiofrequency ablation. The U.S. Food and Drug Administration (FDA) approves radiofrequency ablation as a treatment option for benign thyroid nodules, and medical literature describes it as a minimally invasive approach. However, per the medical records, the patient has very large bilateral thyroid nodules. Reducing the volume of nodules of this size may require multiple sessions, and there is limited published data regarding outcomes of radiofrequency ablation for nodules of this magnitude, making the expected benefit uncertain. In this clinical setting, given the lack of evidence supporting radiofrequency ablation for large nodules, radiofrequency ablation is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN26-46925

11. Overturned 2026 · Medical necessity · age 41–50 Breast proc · Kidney and urinary The physician reviewer found that a patient has requested authorization and coverage for replacement of the existing breast implant and capsulorrhaphy. Medical literature notes that pectus carinatum varies in presentation and that long‑term outcome data for…

    The physician reviewer found that a patient has requested authorization and coverage for replacement of the existing breast implant and capsulorrhaphy. Medical literature notes that pectus carinatum varies in presentation and that long‑term outcome data for treatment approaches are limited. Literature also describes that implant characteristics can influence implant positioning.In this case, pectus carinatum is not visible in the photos received for review; only a prominent manubrium is visible at the upper anterior chest. Breast augmentation is not medically necessary for pectus carinatum because implants are lateral to the sternum and do not conceal the deformity. The photos received for review do not show significant breast asymmetry. The prior breast procedure was an augmentation mastopexy, which is a cosmetic procedure, and any surgical procedure to increase implant size or reposition a flipped implant would be cosmetic in nature. Given these findings, the requested replacement of the breast implant and capsulorrhaphy are not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient presents with breast hypertrophy in severe obesity, which is not an abnormal structure of the body. The patient’s condition is a normal accommodation to marked gain in weight. The patient’s condition is not caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. As such, the California reconstructive surgery statute does not apply to the patient.Therefore, the requested replacement of the right breast implant and capsulorrhaphy are not medically necessary and are not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN26-46918

12. Upheld 2026 · Medical necessity · age 41–50 Breast proc · Malfor/Deform/Abnor The physician reviewer found that a patient has requested authorization and coverage for replacement of the existing breast implant and capsulorrhaphy. Medical literature notes that pectus carinatum varies in presentation and that long‑term outcome data for…

    The physician reviewer found that a patient has requested authorization and coverage for replacement of the existing breast implant and capsulorrhaphy. Medical literature notes that pectus carinatum varies in presentation and that long‑term outcome data for treatment approaches are limited. Literature also describes that implant characteristics can influence implant positioning. In this case, pectus carinatum is not visible in the photos received for review; only a prominent manubrium is visible at the upper anterior chest. Breast augmentation is not medically necessary for pectus carinatum because implants are lateral to the sternum and do not conceal the deformity. The photos received for review do not show significant breast asymmetry. The prior breast procedure was an augmentation mastopexy, which is a cosmetic procedure, and any surgical procedure to increase implant size or reposition a flipped implant would be cosmetic in nature. Given these findings, the requested replacement of the breast implant and capsulorrhaphy are not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function, or (2) to create a normal appearance, to the extent possible. Applying the California reconstructive surgery statute, the requested replacement of the right breast implant and capsulorrhaphy are not reconstructive in nature for this patient. The requested replacement of the right breast implant and capsulorrhaphy will not provide more than minimal improvement in function by addressing pectus carinatum. The requested replacement of the right breast implant and capsulorrhaphy will not be performed to correct or repair an abnormal structure of the body. In this case, the patient does not have significant breast asymmetry. Moreover, the procedures are not intended to improve function and to create a more than minimal improvement in the appearance of the patient. Accordingly, the requested replacement of the right breast implant and capsulorrhaphy are not reconstructive in nature for this patient.Therefore, the requested replacement of the right breast implant and capsulorrhaphy are not medically necessary and are not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested procedures are not medically necessary or reconstructive in nature for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN26-46917